I am seeking restitution in the amount of $ for the following losses and damages I suffered as the result of the commission of the offence.

I declare that I have suffered the following losses and damages as the result of the commission of the offence:

(Complete the following table if seeking restitution.)

Description

(describe each loss and damage)

Amount of loss and damage

(state the amount of each loss and damage)

1.

2.

3.

4.

I understand that the amount of my losses and damages must be readily ascertainable by the court. For that purpose, I am responsible for providing the court with all necessary documents, including bills, receipts and estimates, in support of my claim for restitution.